The contract will fund a clinical study to investigate whether health coaches can augment the care that patients with complex medical issues receive and help reduce unplanned hospitalization and improve overall quality of life. The investigators from Weill Cornell Medicine and CDN, a primary care pratice-based research network, theorize that such support could help patients better manage their everyday challenges and stresses, enabling them to take better care of themselves.

“Previous efforts to reduce hospitalization in patients with multiple chronic conditions focused on intensifying medical management and have not significantly reduced hospitalizations,” said Dr. Charlson, who is also the William T. Foley Distinguished Professor of Medicine at Weill Cornell Medicine and co-principal investigator on the grant. “This project could transform our approach to complex patients through a new strategy aimed at helping them manage life-destabilizing events, or tipping points, that can precipitate a cascade leading to hospitalization and further deterioration.”

For the study, investigators will enroll nearly 2,000 patients in New York and Chicago who are treated at one of 16 Federally Qualified Health Centers—outpatient practices that are Patient-Centered Medical Homes—that provide comprehensive and coordinated medical care and serve predominantly low-income, black and Latino patients. Through a lottery, half of the health centers will implement a new health-coaching program, augmenting regular medical care, which will include positive affect interventions designed to help patients set their own life goals. The investigators will then compare outcomes from patients who participated in the program with those who did not.

“One of the most exciting aspects is that the study will have many partners in New York City and Chicago, including the PCORnet Clinical Data Research Networks (CDRNs)—NYC-CDRN and CAPriCORN—which have information from patients’ complete electronic health records,” said Dr. Tobin, who is also a co-director for Community Engaged Research at The Rockefeller University Center for Clinical and Translational Science, a professor in the Department of Epidemiology and Population Health at Albert Einstein College of Medicine and co-principal investigator on the grant. “The information from PCORnet will be used to help find patients for the study, and then to learn whether they have visited the hospital or emergency room during the study.”

PCORI is an independent, nonprofit organization authorized by Congress in 2010. Its mission is to fund research that will provide patients, their caregivers and clinicians with the evidence-based information needed to make better-informed healthcare decisions. Drs. Tobin and Charlson’s award has been approved pending completion of a business and programmatic review by PCORI staff and issuance of a formal award contract.

“This project was selected for PCORI funding not only for its scientific merit and commitment to engaging patients and other stakeholders, but also for its potential to fill an important gap in our health knowledge and give people information to help them weigh the effectiveness of their care options,” said PCORI Executive Director Dr. Joe Selby. “We look forward to following the study’s progress and working with the Clinical Directors Network and Weill Cornell Medicine to share the results.”